Introduction to liquid biopsy in a Specialized Cancer Center

Transcription

1 Introduction to liquid biopsy in a Specialized Cancer Center Dr. Antonio Cubillo Head, Medical OncologyDepartment HM-CIOCC In collaboration with

2 OUTLINE Need Liquid Biopsy: Definition and techniques Sensitivity and Coverage Applications How did I know about it? Liquid Biosy in HM Hospitales. Conclusions

3 Need for Non-Invasive Molecular Testing Tissue availability for molecular testing varies from 90% (CRC) to 10% (HCC) 25% - 35% inadequate tissue in NSCLC Long lead times for 2 nd opinions from hospital to hospital Complication rate with biopsies 2% major complication rate with lung biopsy 15% minor complication rate Increased need for rapid turn-around time for treatment decisions Early integration of molecular targeted therapies Tumor Heterogeneity (CRC) 0% 13% 19% 32% 33% 50% 0/19 1/8 20/108 10/31 11/33 9/18 Sites with Low Discordance Sites with High Discordance Overman et al, J Clin Oncol 2013, Kopetz et al, ASCO 2014, A3509

4 -Detection of tumor-derived biomarkers in the peripheal blood (or any fluid) of cancer patients -Biomarkers such as DNA, RNA, proteins and mirna can be detected in plasma -These biomarkers can be cellfree or can derive from CTC, exosomes or platelets. LIQUID BIOPSY

5 CIRCULANT TUMOR CELLS (CTCs) 1 CTC/ 10 9 blood cells. Cell Search was approved by FDA (detection of epithelial markers). Number of CTCs depend on stage and tumor type. Prognostic factor in some tumors. RNA can be extracted and analyzed. Lianidou et al, Crit Rev in Lab Sc 2014

6 Communication between cells In cancer, involved in multiple pathways and steps Cancer biomarkers: number, mirna, proteins Cancer therapeutics: deplection, delivery of drugs EXOSOMES Guo et al, Onc Reports 2017

7 TUMOR-EDUCATED PLATELETS Best et al, Cancer Cell 2016 Anucleated cells Role in systemic and local responses to tumor groh Tumor-associated biomolecules sequestration mrna detection à detection of cancer, mutations in some genes (ie RAS, EGFR, PI3KCA) and MET and HER 2+

8 CIRCULATING FREE DNA (cfdna) CHALLENGES The absolute levels are low: few ng/ml of plasma The circulating cell-free DNA (cfdna) contains both ctdna and normal DNA originating form dividing cells The ctdna is only a fraction (<0.1% to 50%) of the cfdna Levels are usually correlated with tumor burden and are higher in advanced cancer Highly fragmented, typically bp range Short half-life (2 hours) Bettegwoda et al, Sci Transl 2014

9 Cell-free tumor DNA in stage IV Localized vs Metastatic Disease (n = 223) Bettegowda et al, Sci Tran Med Feb 2014

10 TECHNIQUES TO DETECT cfdna Wan et al, Nat Rev 2017

11 SENSITIVITY AND COVERAGE Normano et al, ESMO 2017

12 MOLECULAR PROFILING EARLY DIAGNOSIS OF CANCER Applications ctdna detection DETECTING MINIMAL RESIDUAL DISEASE MONITOR RESPONSE TO TREATMENT

13 DNA DETECTION: MOLECULAR Help to detect prognosis and predictive factors. Overcome tumoral heterogenity (detect stem and private mutations). Sensitivity between plasma and tumor is 65-98% depending on tumor type and tecnique. EGFR mutation in NSCLC as the first Liquid Biopsy to be approved. Are ready to be used to select therapies? PROFILING Zang et al, ESMO 2017

14 MOLECULAR PROFILING: KRAS MUTATION Ychou, ESMO 2017

15 MOLECULAR PROFILING EARLY DIAGNOSIS OF CANCER Applications ctdna detection DETECTING MINIMAL RESIDUAL DISEASE MONITOR RESPONSE TO TREATMENT

16 Results Patients Response Issues Plasma genetic status 1, 10, 11, 13, 19, 21, 23, 24, 25, Good responders and still on the study 12/26 (46.2%) Good initial responders but currently off study 9/26 = (34.6%) Fast progression 5/26 = (19.2%) No major issue No major issue tu relapse after 1y tu grow on monotherapy Psychiatric problem Embolization, new mets + died Progression Toxicity Surgery Toxicity Toxicity Surgery Toxicity Progression, died Progression, died Progression Progression Toxicity, progression PIK3CA mutation KRAS switch KRAS switch KRAS switch Wt BRAF mutation BRAF mutation BRAF mutation BRAF mutation

17 Preliminary results Patients Response Issues Plasma genetic status 1, 10, 11, 13, 19, 21, 23, 24, 25, Good responders and still on the study 12/26 (46.2%) Good initial responders but currently off study 9/26 = (34.6%) Fast progression 5/26 = (19.2%) No major issue No major issue tu relapse after 1y tu grow on monotherapy Psychiatric problem Embolization, new mets + died Progression Toxicity Surgery Toxicity Toxicity Surgery Toxicity Progression, died Progression, died Progression Progression Toxicity, progression PIK3CA mutation KRAS switch KRAS switch KRAS switch Wt BRAF mutation BRAF mutation BRAF mutation BRAF mutation

18 Patient N 3 % N mutant allele vol (mm) lung metastasis FOLFORI-Cetuximab Cetuximab monotherapy circulating KRAS G12D months

19 Preliminary results Patients Response Issues Plasma genetic status 1, 10, 11, 13, 19, 21, 23, 24, 25, Good responders and still on the study 12/26 (46.2%) Good initial responders but currently off study 9/26 = (34.6%) Fast progression 5/26 = (19.2%) No major issue No major issue tu relapse after 1y tu grow on monotherapy Psychiatric problem Embolization, new mets + died Progression Toxicity Surgery Toxicity Toxicity Surgery Toxicity Progression, died Progression, died Progression Progression Toxicity, progression PIK3CA mutation KRAS switch KRAS switch KRAS switch Wt BRAF mutation BRAF mutation BRAF mutation BRAF mutation

20 baseline Patient N 7 62 yo man with stage IV CCR with liver metastatic disease. He received a first line treatment with FOLFIRI+cetuximab with a good response. after treatment Surgery of the liver mets was then considered In order to increase the volume of liver remaining after the hepatectomy an embolization was performed. After surgery there was no evidence of disease in the CT scan. after surgery

21 baseline Patient N 7 62 yo man with stage IV CCR with liver metastatic disease. He received a first line treatment with FOLFIRI+cetuximab with a good response. after treatment Surgery of the liver mets was then considered In order to increase the volume of liver remaining after the hepatectomy an embolization was performed. After surgery there was no evidence of disease in the CT scan. after surgery

22 Patient N 7 Three months after surgery, the patient developed a very aggressive tumor relapse with multiple metastases in the lung, bone, liver and mediastinum and died shortly after.

23 Three months after surgery, the patient developed a very aggressive tumor relapse with multiple metastases in the lung, bone, liver and mediastinum and died shortly after. bone mediastinum liver lung 905 copies FOLFIRI+ KRAS mutation cetuximab Liver embolization Tumor relapse Liver surgery KRAS circulating mutation tumor burden

24 Three months after surgery, the patient developed a very aggressive tumor relapse with multiple metastases in the lung, bone, liver and mediastinum and died shortly after. bone mediastinum liver lung 905 copies FOLFIRI+ KRAS mutation cetuximab Liver embolization Tumor relapse Liver surgery KRAS circulating mutation tumor burden

25 Conclusions This is the first prospective clinical trial to study ct mutations on the management of mcrc patients. The plasma analyses correlated 100% with the analyses of the tumors in our cohort. The rate of KRAS switch on mcrc patients on FOLFIRI + cetuximab was low. Cubillo&Toledo. Oncotarget 2016

26 MONITORING RESPONSE TO TREATMENT in mcrc: cfdna Higher reduction predicts response according to RECIST Tie et al, Ann Oncol 2015

27 MONITORING RESISTANCE TO TREATMENT: RAS mcrc RAS mcrc is treated withanti- EGFR therapy. Main acquired resistance are RAS mt. Acquisition of KRAS mutation 10 months prior to radiological assesment (BEAMing). Misale et al, Nature 2012

28 Servicio de Identificación de Biomarcadores en Biopsia Líquida Idylla Mutaciones Gen Exón Codón Mutación Método Formato Proveedor G12C G12R G12S 12 2 G12A G12D G12V 13 G13D K-RAS 61 Q61K Q61K Q61L Q61R 3 Q61H Q61H A59T A59E A59G K117N K117N 4 A146P 147 A146T A146V G12C G12S 12 G12A 2 G12D G12V G13R 13 G13V G13D N-RAS Q61K Q61L 3 61 Q61R Q61H Q61H 59 A59T K117N K117N 146 A146T A146V BRAF V600E V600E V600D V600K V600R EGFR S492R QRT-PCR QRT-PCR QRT-PCR Kit individual 01 Kit individual 02 Kit individual 03 Biocartis KRAS mutations are observed in: Colorectal Cancer (46% (2) ) Lung Cancer (15-25% (3) ) Pancreatic Cancer (>90% of PDAC (4) ) BRAF mutations are observed in: Colorectal Cancer (8-15% (3) ) Melanoma (50% (3) ) Lung Cancer (1-4% (3) of all NSCLC) EGFR S492R mutations are observed in: Colorectal Cancer (16% (5) ) as a mechanism of resistance (during anti-egfr antibody therapy) NRAS mutations are observed in: Colorectal Cancer (5% (2) ) Melanoma (13-25% (3) ) Real Time-PCR Source: (1)Adrienne D. Cox et al. Drugging the undruggable RAS: Mission Possible? Nature Reviews Drug Discovery 2014 Volume:13,Pages: (2) Douillard et al., Panitumumab FOLFOX4 Treatment and RAS Mutations in Colorectal Cancer, N Engl J Med 2013;369: (3) (4) Jochen K. Lennerz et al. Allelic Ratio of KRAS Mutations in Pancreatic Cancer. The Oncologist, April 2015 (5) Montagut C. et al., Identification of a mutation in the extracellular domain of the Epidermal Groh Factor Receptor conferring Cetuximab resistance in CRC. Nature medicine 2012

29 Servicio de Identificación de Biomarcadores en Biopsia Líquida OncoSELECT (Lung, Breast and Colon cancer panels) OncoKDO: Desarrollo de una plataforma propia para el análisis e interpretación de resultados, con recomendaciones de tratamiento preferente. * Revisión de opciones terapéuticas en España y Europa actualizada. OncoSHARE: plataforma que permite almacenar, consultar y compartir resultados (anonimizados) **El panel de cáncer de pulmón incluye el análisis en ARN de traslocaciones en ALK/ROS1/RET/NTRK1-3 y el salto de exón Met-ex14

30 Servicio de Identificación de Biomarcadores en Biopsia Líquida OncoTRACE (Panel 40 genes)** OncoKDO: Desarrollo de una plataforma propia para el análisis e interpretación de resultados, con recomendaciones de tratamiento preferente. * Revisión de opciones terapéuticas en España y Europa actualizada. OncoSHARE: plataforma que permite almacenar, consultar y compartir resultados (anonimizados) ** Se pueden incluir hasta 15 alteraciones adicionales para personalizar la monitorización % 45 % 13 % % 15 %

31 Servicio de Identificación de Biomarcadores en Biopsia Líquida Extracción de sangre (2x 10ml) Extracción de Plasma Separación en alicuotas #1 #2 #3 #4 #5 Análisis 01 KRAS Análisis 02 NRAS Análisis 03 BRAF/EGFR Análisis 04 Panel 21 (Tubos Streck) Seroteca

32 Servicio de Identificación de Biomarcadores en Biopsia Líquida KRAS NRAS BRAF/EGFR OncoSELECT OncoTRACE (40 genes) Order T0 Report T 3d Order T0 Report T 7d

33 Clinical experience at HM Hospitales Studies in liquid biopsy available for all hospitals of the HM Group, Madrid (Spain) through Abacid, innovation human labs Starting in clinical routine: July, 2017 Studies performed to date: 95 (5 in progress) Main cancer types analyzed Colorectal cancer 28% Pancreatic cancer (Research Project) 26% Breast cancer 13% Non-Small Cell Lung Cancer 8% Others 24% Main mutations detected KRAS 38% TP53 25% PTEN 9% HRAS 6% Others 22% 33

34 Clinical experience at HM Hospitales Studies in liquid biopsy available for all hospitals of the HM Group, Madrid (Spain) through Abacid, innovation human labs Starting in clinical routine: July, 2017 Studies performed to date: 95 (5 in progress) Results % of patients in whom alterations have been detected 70% % of patients with pathogenic/actionable mutations % of studies with therapeutic impact, recommendation of a new treatment 48% 38% ü ü ü ü ü Pronostic and therapeutic implications Monitoring tool Target therapy Clinical trials Resistance 34

35 CONCLUSIONS Liquid Biopsy refers to tumor biomarkers in any biologic fluid: DNA, RNA, proteins, CTCs, exosomes. cfdna can be measured with different techniques: the higher sensitivity, the narrower coverage. It is a clear need for our patients, Help physicians to make their next treatment decision. It is used in usual clinical practice to get Molecular profiling and monitore the response to therapy. Future uses in minimal residual didease and diagnostic are very, very near to the clinical practice.

36 Dr. Antonio Cubillo Head, Medical Oncology Department HM-CIOCC QUESTIONS? In collaboration with